Treatment of migraine with monoclonal antibodies

ABSTRACT

Introduction

In the few last years, a new family of drugs, anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs), has been developed for migraine therapy. Anti-CGRP mAbs are highly effective, but the current limited experience with their use and their high-cost warrant establishing certain rules of use.

Areas covered

The present review provides an overview of the management of migraine patients, especially those who are undergoing treatment with anti-CGRP mAbs.

Expert opinion

Thanks to new research focused on the pathophysiology of migraine, and the discovery that CGRP plays a key role in its etiopathogenesis, new drugs targeting CGRP have been developed. These drugs have led to a paradigm shift, anticipating new and stimulating possibilities in migraine treatment. While physicians and patients are full of expectation about the advantages of this new family of drugs, there are still obstacles to overcome in order to make the best use of them. It is essential to form multidisciplinary teams that can identify patients who will benefit from these therapies, conducting cost-effective treatments. The follow-up of these therapies in the coming years is paramount due to the lack of experience in the management of these drugs and the peculiarity of disease evolution in migraine patients.

KEYWORDS:

• CGRP
• monoclonal antibodies
• migraine
• erenumab
• galcanezumab
• fremanezumab
• eptinezumab

Article highlights

• Anti-CGRP mAbs have proven to be an effective therapy in the preventive treatment of migraine, achieving a 50% reduction in days of migraine per month in a significant percentage of patients, even in those who are resistant to other therapies.

• The safety profile of these drugs is highly favorable. The most commonly reported side effects are application site reactions (erythema, induration and pain) with subcutaneous administration and constipation.

• Nevertheless, there is a need to monitor the long term the safety of these treatments, as well as their impact on quality of life, in order to have an overall view of their long-term efficacy and safety in clinical practice.

• Although the CGRP pathway is not the only migraine mechanism, it has important implications for the pathophysiology of migraine. Its increase can be an intercritical marker of chronic migraine.

• Anti-CGRP antibodies do not increase the prevalence of COVID-19 in patients treated with these agents, completely ruling out the doubtful connection between them and viral infection.

• Anti-CGRP antibody therapy ideally requires the formation of multidisciplinary teams, including nurses and psychologists, capable of managing it safely and effectively.

• In public healthcare systems, it is essential to design a system that guarantees optimal use of these therapies as well as equitable accessibility to the entire population.

This box summarizes key points contained in the article.

Declaration of interest

JM Serra Lopez-Matencio has received honoraria from Bristol-Myers Squibb, Eli Lilly and Janssen. S Castañeda has received grants/research supports from Merck Sharp & Dohme and Pfizer and has received consultation fees for participating in company-sponsored speaker´s bureaus for Amgen, Bristol-Myers Squibb, Merck Sharp & Dohme, Gedeon Richter, Grünenthal, Eli Lilly, Menarini, Roche, Sanofi, Swedish Orphan Biovitrum, Stada and Union Chimique Belge. Furthermore, S Castañeda is assistant professor of the Cátedra UAM-Roche, EPID-Future, Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain. AB Gago-Veiga has received honoraria from Eli Lilly, Novartis, TEVA Pharmaceuticals, Abbvie-Allergan, Exeltis and Chiesi. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they are an employee of Lundbeck. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.